It is barely a month into the new year and healthcare workers and their security personnel continue to be mercilessly targeted. Pakistan has already recorded four cases of polio and the death of three healthcare workers on an anti polio drive.

In the latest incident six policemen on their way to provide security to a polio team were killed in Charsadda on Wednesday. However, it is not confirmed if they were the intended target due to their association to the anti polio drive.

There were 19 polio-related killings in 2013 which included 10 healthcare providers and nine police personnel. As many as 22 people were reported injured during the same period.

The Tehreek-i-Taliban Pakistan (TTP) claimed responsibility for the attacks calling the campaign un-Islamic and a rouse for Western conspiracies and agendas.

But Dawn's special correspondent Hasan Abdullah who covers militancy says there is a difference of opinion within the ranks of the TTP on the targeting of healthcare workers. According to Abdullah, the senior leadership of the militant organisation does not oppose the anti polio drive but is reluctant to issue an official statement allowing polio vaccinations for a number of reasons.

“First of all, they want to create a consensus on the issue before making any statement,” he says adding: “Second, they still believe that espionage operations may be carried out under the garb of vaccination campaigns so they do not want to give a blanket green signal.”

Secretary General for the Wafaq ul Madaris al Arabia Pakistan and a member of the council of Islamic Ideology, Qari Muhammad Hanif Jallandhri rubbishes the Taliban’s claims. “These vaccines are essential for our children and there is nothing un-Islamic about them,” he says. Taking initiative Jallandhri’s federation has spoken extensively with doctors and declared that polio vaccines are not against the Shariah.

“This is just an injustice against our children and our country and is sabotaging our future,” says the renowned cleric. He further urges parents to be more aware vis a vis the health and wellbeing of their children. “They (parents) themselves should take their children to get vaccinated. That way they protect their children and not put the polio teams in any danger they way they are now.”

Pakistan is one of only three countries where polio remains endemic. Afghanistan has shown substantial improvement in their efforts with aggressive campaigns at its border areas, a major reason behind Balochistan’s relative success in controlling polio cases in 2013. On the other hand, Pakistan reported 91 children infected with the polio virus last year, higher than the 58 cases in 2012 but notably lower than the 198 cases in 2011.

The year’s first nationwide vaccination campaign began amidst talks of Pakistan drastically limiting the number of polio cases this year. However, as bodies of health workers pile up and anti polio drives subsequently get suspended officials fear the polio count will substantially rise. It is important to mention here that the WHO recently declared Peshawar as the largest ‘reservoir of polio’ in the world.

On the other hand, urban centres such as Karachi were considered relatively safer but over the last couple of years the unstable security situation has seriously damaged the anti polio initiative. In 2012 five healthcare workers were killed while there was an unsuccessful attack on a team in 2013. The latest attack on a team working in Qayyumabad left three dead and one injured.

“No matter how much this act (of killing of healthcare workers) is condemned, it is not enough,” says deputy director for the Expanded Immunisation Initiative Dr Durrenaz Kazi.

When Karachi started getting targeted, the high risk areas included mainly Gadap and Baldia, according to Kazi. “In fact on the first day of the campaign on January 20 the police personnel escorting the team outnumbered the healthcare workers in Baldia.”

But Qayyumabad was marked as “a safe or low threat zone”. So much so that there was no police deployed with the two teams which were working simultaneously on the opposite sides of the same street when they were targeted. “Now all of Karachi is a high risk zone and we need to completely reassess our plans,” she adds.

According to Kazi, Karachi will now be ‘vaccinated in phases’ to ensure the over 8,000 members involved in the anti polio drive can be sufficiently provided security. After the death of the healthcare workers, the campaign was suspended but not cancelled; however, there was no confirmed date for resuming the drive till this report was published.

Calling healthcare workers “frontline force against polio” Prime Minister’s focal person on polio eradication Ayesha Raza Farooq asks the questions many have echoed recently: “Why would anyone want to kill someone who is trying to protect their children?”

According to Farooq, they are “rethinking the entire strategy” and need some time to finalise their next course of action. But there is no doubt that “stringent measures will be implemented, we have lost too many workers already.” Almost in the same breath though she adds, “At the same time we need to keep on with our (anti polio) efforts, we simply cannot let these cowardly acts deter us from our cause.”

National technical focal person for Prime Minister’s Polio Monitoring Cell Dr Altaf Bosan offers a few suggestions. Strengthening coordination between the vaccination teams and security personnel especially in Central Khyber Pakhtunkhwa and Karachi is one. “Our best strategy is ‘protected campaigns’,” Bosan says. He also proposes other solutions such as ‘mini curfews’ for a few hours in the areas being covered during which the vaccinators can easily administer the vaccine to children.

Afghanistan’s anti polio drive

To better understand the reasons behind Afghanistan’s relative success in limiting the number of polio cases, Dawn.com contacted Dr Asmatullah Arab who is the focal person for the Gates Foundation in Afghanistan.

Of the 13 cases in 2013, 12 were from the country’s eastern regions including Kunar and Kandahar which border with Pakistan while one was reported from Helmand. As of June 2013, the Afghan Taliban announced their support and cooperation for the anti polio drive and provide safe passage to polio workers in the area. “There are some conditions though,” Arab explains. “Only local healthcare providers are permitted and no expatriate is allowed to enter but since this arrangement we have not had any problems in the area.”

While it is difficult to monitor the extent of the campaign’s success from afar, the ‘non polio rate’ in the area provides a good indicator, Arab elaborates.

Since the announcement there is ongoing communication and close coordination between the negotiator and the Taliban on this issue. “They (Taliban) are taking ownership of the eradication initiative saying: we need to eliminate polio from our country and save our children from being crippled,” Arab says.

Pakistan-Afghanistan coordination on anti polio initiatives

According to genetic coding of the virus strain, a majority of cases in Afghanistan are linked with Pakistan, says Arab. “We had a meeting in May 2013 to strengthen Pakistan-Afghanistan coordination but nothing concrete since then.”

In some areas, for example Helmand, and some parts of Kandahar, 70 to 80 per cent of the campaign work and funding has been handed over to the Taliban which is closely monitored by authorities.

Back in Pakistan, Farooq says it would be unfair to draw analogies between the two countries. “Pakistan is on the frontline of the war on terror and often bears the brunt of fall-outs of international politics.”

Further, she adds: “No country has a ban on vaccination so people need to understand that we are dealing with a number of issues.”